Basic Information
Provider Information | |||||||||
NPI: | 1235149998 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KUTZ | ||||||||
FirstName: | SUSAN | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | APN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | BOX 78534 | ||||||||
Address2: |   | ||||||||
City: | MILWAUKEE | ||||||||
State: | WI | ||||||||
PostalCode: | 53278 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8153817431 | ||||||||
FaxNumber: | 8153817498 | ||||||||
Practice Location | |||||||||
Address1: | 5875 E RIVERSIDE BLVD | ||||||||
Address2: |   | ||||||||
City: | ROCKFORD | ||||||||
State: | IL | ||||||||
PostalCode: | 611144937 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8153989491 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/08/2006 | ||||||||
LastUpdateDate: | 02/05/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/05/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WR0006X | 041277987 | IL | N |   | Nursing Service Providers | Registered Nurse | Registered Nurse First Assistant | 363L00000X | 209-010941 | IL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
No ID Information.